Acad Psychiatry
DOI 10.1007/s40596-017-0794-1
IN DEPTH ARTICLE: SYSTEMATIC AND OTHER REVIEWS
Prevalence of Internet Addiction in Medical
Students: a Meta-analysis
Melvyn W. B. Zhang 1,2 & Russell B. C. Lim 3 & Cheng Lee 1 & Roger C. M. Ho 3
Received: 27 April 2017 / Accepted: 25 July 2017
# Academic Psychiatry 2017
Abstract
Objective With the development of online learning, commu-
nication, and entertainment, the Internet has become an indis-
pensable tool for university students. Internet addiction (IA)
has emerged as a health problem and the prevalence of IA
varies from country to country. To date, the global prevalence
of IA in medical students remains unknown. The objective of
this meta-analysis was to establish precise estimates of the
prevalence of IA among medical students in different
countries.
Methods The pooled prevalence of IA among medical stu-
dents was determined by the random-effects model. Meta-
regression and subgroup analysis were performed to identify
potential factors that could contribute to heterogeneity.
Results The pooled prevalence of IA among 3651 medical
students is 30.1% (95% confidence interval (CI) 28.5–
31.8%, Z = −20.66, df = 9, τ2 = 0.90) with significant hetero-
geneity (I2 = 98.12). Subgroup analysis shows the pooled
prevalence of IA diagnosed by the Chen’s Internet Addiction
Scale (CIAS) (5.2, 95% CI 3.4–8.0%) is significantly lower
than Young’s Internet Addiction Test (YIAT) (32.2, 95% CI
20.9–45.9%) (p < 0.0001). Meta-regression analyses show
that the mean age of medical students, gender proportion
and the severity of IA are not significant moderators.
* Melvyn W. B. Zhang
Melvyn_wb_zhang@imh.com.sg
1
National Addictions Management Service, Institute of Mental
Health, Singapore, Singapore
2
National University of Singapore, Singapore, Singapore
3
Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Singapore
Conclusions In conclusion, this meta-analysis identified the
pooled prevalence of IA among medical students is approxi-
mately five times than that of the general population. Age,
gender, and severity of IA did not account for high heteroge-
neity in prevalence, but IA assessment questionnaire was a
potential source of heterogeneity. Given the high prevalence
of IA, medical teachers and medical school administrators
should identify medical students who suffer from IA and refer
them for intervention.
Keywords Internet addiction . Medical students .
Meta-analysis . Prevalence, problematic Internet use
With the rapid advance in technologies over the past decade,
the Internet has become an integral part of the lives of many
individuals. Widespread Internet access has benefited people
by improving access to online information and providing new
opportunities for social communication and entertainment [1].
Although the Internet has offered advantages, excessive usage
of the Internet is associated with a psychiatric condition
known as Internet addiction (IA) [2, 3]. IA mimics other forms
of addiction and is characterized by an inability to inhibit
Internet use despite negative impact on physical health and
psychosocial functioning [4–7].
Previous studies have highlighted the importance of study-
ing IA in university students because they are more likely than
the general population to use the Internet [1] and vulnerable to
develop IA [8]. Additionally, university students have an im-
mediate desire to engage in online activities because the
Internet is readily available on laptop computers and
smartphone devices [1]. Previous studies report the prevalence
of IA among university students to vary between 4% in the
USA [9] and 16.8% in Italy [10].

Meta-analysis is a statistical procedure used for combining
the results of a number of studies in order to estimate a pooled
effect size [11, 12]. Although previous meta-analysis studied
the pooled prevalence of depression among medical students
in different countries [13, 14], the pooled prevalence of IA
remains unknown. In more recent work, IA was found to be
associated with atrophy in the prefrontal cortex and cognitive
impairment [4]. Such cognitive impairment could significant-
ly affect the academic performance of medical students and
fitness to practice after graduation. For this purpose, the cur-
rent meta-analysis aimed to establish the pooled prevalence of
IA among medical students in different countries.
Methods
A comprehensive search was conducted from January 1,
2017, to February 20, 2017. The following databases were
searched: PubMed (since 1966), Embase (since 1980),
PsychINFO (since 1806), BIOSIS (since 1926), Science
Direct (since 2006), and Cochrane CENTRAL (since 1993).
The search terminologies included permutations of the key-
words for IA (e.g., Internet addiction, problematic internet
use) and medical students, medical undergraduates.
The inclusion criteria for this meta-analysis were as fol-
lows: (a) undergraduate medical students formed the main
cohort of the study population, (b) the severity of IA was
measured by a validated questionnaire, and (c) prevalence of
IA was the primary outcome of the study population. The
exclusion criteria were as follows: (a) a study without an ab-
stract written in English and (b) insufficient information to
compute the pooled prevalence of IA.
Articles were de-identified (author(s), year of publication,
and journal name) before data extraction [15]. Selection of the
relevant publications was conducted independently by two
authors, namely that of MWBZ and RL. In the first phase,
articles were screened based on their titles and abstracts. The
shortlisted articles were then evaluated against the aforemen-
tioned inclusion and exclusion criteria. In the event of any
disagreement between two authors, it was resolved by discus-
sion with the last author, RCMH. All procedures conformed to
the guidelines for meta-analysis of observational studies in
epidemiology and preferred reporting items for systematic re-
views and meta-analyses where appropriate [16, 17].
The following information was extracted from each of the
article, cross-checked by the second author and the last author,
and recorded on a standardized electronic data collation form:
(a) publication details (names of the authors and year of pub-
lication), (b) the number of medical students diagnosed with
IA, (c) the total sample size for each study, (d) the mean age of
participants, (e) the proportion of male and female partici-
pants, and (f) the name of assessment questionnaire used to
assess IA, and (g) the mean IA score of all participants.
Acad Psychiatry
All statistical analysis was performed using the
Comprehensive Meta-Analysis Version 2.0 based on
random-effects model and methods established by previous
studies [18–20]. The random-effect model was used because
it assumes varying effect sizes between studies, because of
differing study design and study population [21]. The assump-
tion of homogeneity of effect sizes, that is, τ2 = 0, can be tested
by a chi-square statistic which is usually known as the Q
statistic [22]. Between-study heterogeneity was assessed with
the I2 statistic, which describes the percentage of variability
among effect estimates beyond that expected by chance [23].
As a reference, I2 values of 25% are considered low, 50%
moderate, and 75% high heterogeneity [24].
Meta-regression was performed to identify demographic
and disease-related factors that might contribute to the hetero-
geneity [25] and predict the effective size [26]. The regression
coefficients and the associated z values and p values were
reported in the meta-regression analysis [27]. Subgroup anal-
ysis was undertaken to investigate the effects of categorical
variables on the pooled prevalence of IA. We compared the
prevalence of IA between subgroups based on the question-
naires used to assess IA.
Egger’s regression test was conducted to determine if pub-
lication bias was present [28]. If significant publication bias
was present, the classic fail-safe test was performed to deter-
mine the number of missing studies that are required in order
for the p value of the publication bias among the observed
studies to be higher than 0.05.
Results
A cumulative total of 129 citations were identified using the
search strategy and screened. One hundred fourteen articles
were excluded because these studies recruited non-medical
university students or failed to provide sufficient data to cal-
culate effect size. Fifteen articles were further reviewed based
on inclusion and exclusion criteria. One article was excluded
because it did not provide access to the full text. Three studies
were excluded because they included subjects who were
studying in basic medical science but not medicine. One study
was excluded because it included postgraduate students. The
final data set consisted of 10 studies with a total of 3651
participants. The characteristics of studies included are de-
scribed in Table 1.
The pooled prevalence of IA among 3651 medical stu-
dents is 30.1% (95% confidence interval 28.5–31.8%,
Z = −20.66, df = 9, τ2 = 0.90, I2 = 98.12). This meta-
analysis demonstrates significant heterogeneity across
studies (p < 0.0001). Figure 1 shows the forest plot gen-
erated for the pooled prevalence of IA among medical
students. The meta-regression analyses show that the
mean age of the medical students (β = 0.13, 95%
Acad Psychiatry

Table 1 Baseline characteristics of studies included

Study Study Study design Prevalence Number Total Proportion Proportion Mean IA Mean score
location of of ample of male of female age assessment on IA
Internet students size students students (years) questionnaire questionnaire
addiction ddicted (n) (%) (%)
(%) (n)

Fetahi R et al. [8] Iran Cross-sectional 16.1 28 174 44.3 55.7 NA Young Internet 34.13
Addiction Test
Nath K et al. [29] India Cross-sectional 46.8 88 188 60.6 39.4 22.51 Young Internet NA
Addiction Test
Juan EB et al. Chile Cross-sectional 11.5 44 384 58.3 41.7 20.78 Young Internet 34.77
[30] Addiction Test
Zoi Tsimtsiou Greece Cross-sectional 30.1 161 534 43.6 56.4 21.3 Young Internet 25.4
et al. [31] Addiction Test
Chaudhari B India Cross-sectional 58.9 166 282 43.26 56.74 19.9 Young Internet NA
et al. [32] Addiction Test
Farhad Ghamari Iran Cross-sectional 10.8 46 426 35.1 64.9 NA Young Internet 32.74
et al. [33] Addiction Test
Maryam Selehi Iran Cross-sectional 5.22 20 383 38.9 61.1 21.79 Chen Internet 43.32
et al. [34] Addiction Scale
Haque M et al. Malaysia Cross-sectional 80.5 120 149 40.3 55.7 22 Young Internet 43.15
[35] Addiction Test
Ching SM et al. Malaysia Cross-sectional 36.9 157 426 36.6 63.4 21.6 Young Internet NA
[36] Addiction Test
Boonvisudhi T Thailand Cross-sectional 24.4 172 705 44.3 55.7 20.51 Young Internet NA
et al. [37] Addiction Test

NA not available

CI = −0.94–1.21, Z = 0.24, p = 0.81), gender proportion
of male medical students (β = 0.0091, 95% CI = −0,084–
0.10, Z = −0.19, p = 0.85), and severity of IA (β = 0.13,
95% CI = −0.036–030, Z = 1.53, p = 0.12) are not sig-
nificant moderators accounting for heterogeneity. Based
on the subgroup analysis, the pooled prevalence of IA
diagnosed using the CIAS (5.2, 95% CI 3.4–8.0%) is sig-
nificantly lower than YIAT (32.2, 95% CI 20.9−45.9%)
(p < 0.0001). For publication bias, the Egger’s regression
test shows that publication bias is not significant in this
meta-analysis (intercept = −3.55, 95% CI−21.4–14.25,
t = 0.46, df = 8, p = 0.657).
Discussion
To our knowledge, this is the first meta-analysis that examined
the prevalence of IA among medical students in different coun-
tries. Our most important result is that the prevalence of IA
among 3651 medical students is 30.1%. In one meta-analysis,
the global prevalence of IA among the general population was
found to be 6% in 31 different countries [4]. In another study, the
prevalence of IA among adolescents assessed by the YIAT was
found to be 5% in six different Asian countries [38]. This meta-
analysis highlights that the prevalence rate of IA among medical
students was almost five times higher than that of the general
population. The prevalence of IA was higher than global preva-
lence of depression in medical students which is 28.0% [14]. The
high prevalence rate of IA is a major concern because medical
students are trained to become health professionals. IA may af-
fect patient safety [10] because it is associated with cognitive
impairment [4]. Such impairment can affect medical student’s
abilities to concentrate during academic study or clinical place-
ment [39]. Furthermore, IA is associated with poor quality of life
[40]. There are several reasons that account for higher prevalence
of IA among medical students. First, the accessibility hypothesis
suggests that medical students are more vulnerable to IA due to
frequent use of the Internet to search for medical information as
well as participating in online learning and assessment [8].
Second, medical students may immerse themselves into the vir-
tual reality of the Internet to escape from academic stress [41].
Third, the use of the Internet as a coping strategy for negative
psychological states (e.g., stress or depression) may perpetuate
IA because students suffering from IA often avoid socialization
with other people [1].
Meta-regression analyses demonstrate that continuous
variables such as mean age, proportion of gender, and
severity of IA are not significant moderators and do not
account for the heterogeneity in the pooled prevalence of
IA among medical students. Our findings suggest that
gender may not play a key role in IA. This can be an
emerging trend when both genders have equal access to
 Acad Psychiatry

Prevalence of Internet Addiction among Medical Students

Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper
rate limit limit Z-Value p-Value
Fetahi R et al. (2016) 0.000 0.161 0.113 0.223 -8.004 0.000
Nath K et al. (2016) 0.000 0.468 0.398 0.540 -0.875 0.382
Juan EB et al. (2014) 0.000 0.115 0.086 0.150 -12.763 0.000
Zoi Tsimtsiou et al. (2015) 0.000 0.301 0.264 0.342 -8.910 0.000
Chaudhari B et al. (2015) 0.000 0.589 0.530 0.645 2.962 0.003
Farhad Ghamari et al. (2011) 0.000 0.108 0.082 0.141 -13.526 0.000
Maryam Selehi et al. (2014) 1.000 0.052 0.034 0.080 -12.620 0.000
Ching SM et al. (2017) 0.000 0.360 0.316 0.406 -5.763 0.000
Haque M et al. (2016) 0.000 0.805 0.734 0.861 6.863 0.000
Boonvisudhi T et al. (2017) 0.000 0.244 0.214 0.277 -12.898 0.000
0.301 0.285 0.318 -20.661 0.000
-1.00 -0.50 0.00 0.50 1.00

Fig. 1 Forest plot of pooled prevalence of Internet addiction among medical students

the Internet [40], especially for medical students. The sub-
group analysis demonstrates that there is a significant dif-
ference in the prevalence of IA between participants
assessed by YIAT and CIAS; therefore, the questionnaires
assessing IA is a potential source of heterogeneity.
Previous study advised researchers to interpret the preva-
lence of IA assessed by the CIAS with caution because it
was validated in Chinese population but not in other pop-
ulations [38, 43]. In this meta-analysis, the study which
used CIAS was conducted in Iran.
This meta-analysis has several limitations. First, we did
not have information on other factors including the pur-
pose of using the Internet (e.g., playing online games,
usage of social media), the percentage of individuals
who have access to the Internet in each country of study,
quality of life of participants, family history of addiction,
and academic performance [4, 44]. These factors could
influence the pooled prevalence of IA. Second, this
meta-analysis is based on six different countries (3 studies
from Iran, 2 studies from India, 2 studies from Malaysia,
1 study from Chile, 1 study from Greece and 1 study from
Thailand). We could not locate studies conducted in
Australia, East Asia, Europe, and North America during
our search. This limitation is noteworthy because it limits
the generalizability of results. Further studies focusing on
the prevalence of IA among medical students are required
from these continents. Third, the studies included in this
meta-analysis are cross-sectional and this meta-analysis is
not able to demonstrate causality or temporal association
between IA and undergraduate medical studies. Fourth,
we could not perform subgroup analysis to compare the
prevalence of IA between medical students from junior
and senior years.
Our results have implications for administrators and med-
ical teachers in medical schools. The high prevalence of IA
among medical students suggest that medical teachers should
be able to recognize signs of IA including inability to reduce
internet use, psychological dependency, and withdrawal
symptoms [1]. Prompt recognition of IA will facilitate referral
for early intervention by mental health professionals. Early
intervention can prevent further deterioration of IA and poten-
tial negative impact on quality of life [40]. Given the associ-
ation between IA and other psychiatric disorders, it is of im-
portance to screen for other psychiatric comorbidity including
depression and sleep deprivation when assessing medical stu-
dents suffering from IA. University students found IA as key
factor for sleep deprivation [1] because students stay awake
during late night hours to surf the Internet [42]. For medical
students, the lack of sleep may lead to lack of concentration in
lectures, tutorials, and bedside teaching. In addition, sleep
deprivation is associated with impairment in executive func-
tioning [45]. Such impairment is detrimental to medical stu-
dents and junior doctors because it affects decision-making
ability and patient safety [10]. Medical educators should in-
crease the awareness of IA among medical students by teach-
ing about IA in undergraduate psychiatry courses. Mental
health professionals can offer motivational interviewing, cog-
nitive behaviour therapy, virtual-reality therapy [46] and psy-
chotropic medications to treat psychiatric comorbidity associ-
ated with IA.
In conclusion, this meta-analysis reports that the
pooled prevalence of IA among medical students from
different countries is 30.1%, which is approximately five
times than that of the general population. Age, gender,
and severity of IA cannot explain high heterogeneity in
prevalence, but IA assessment questionnaire are a poten-
tial source of heterogeneity. Given the high prevalence of
IA, medical teachers and medical school administrators
should identify medical students suffering from IA and
refer them for intervention. The undergraduate psychiatric
curriculum should cover IA and increase the awareness of
IA among medical students.
Acad Psychiatry
Compliance with Ethical Standards
Disclosure On behalf of all authors, the corresponding author states that
there is no conflict of interest.
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